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Sunday, September 27, 2009

In my continuing series on posts for first year medical students, I decided to write a post on study tips and strategies for first year students. Of course, some of these tips could apply to any student, but there is a definite adjustment that has to be made for studying medical knowledge. Some of these things I learned from friends; some, from my own mistakes. Hopefully you can incorporate them into your own study strategies to be a successful medical student.

Study every single day - Being a good student requires developing good study habits. As cliche as this is, it is really really important in medical school, much more so than in college or high school. There is a huge volume of material being presented, and it is very easy to fall very far behind. Even if you can't study every single day, try to read at least a little bit whenever you can.

Translate the notes you receive into your own condensed, easy-to-read version - This helps you internalize the knowledge in a way you can easily access. If you find yourself having trouble doing this, it is usually a good sign that either the material was not presented well or you are not fully understanding it (or both). Besides, such study guides will help immensely down the road when you have to study for USMLE Step I.

Use visual cues - Imagine 10 years from now (or even 2 years), you are participating in a gastric bypass bariatric surgery procedure. The procedure is being doing laparoscopically, and the attending physician points to a section of the GI tract, asking you to identify it. If you study visually, this will trigger images from your basic science years, and such identification should be easy. However, if you only study via text or via one view of the abdomen, such identification may prove very challenging.

Take study breaks - I know, this contradicts the tips that came before. But it is really important to maintain balance in studying, and to take appropriate study breaks. I would suggest taking a 2 to 5 minute break every hour, and a 30 minute break every 3 hours. And, in general, have one day a week where you study only an hour or not at all. Your mind needs time off to process all the information you are trying to cram into it.

Study in a group - Again, somewhat cliched advice, but I think the key here is to choose your friends wisely and to strictly limit how much time you study with them. Ideally, you should do all your studying on your own, and use group studying time as a review or to clarify confusing points. The sessions should be rapid fire and limited to no more than an hour or two a week. I studied with friends much more than this amount, but looking back on it, I am not sure how efficient such studying was. The ideal study group is one with similar views on studying and work ethic that complements your knowledge base well.

Study what matters - A lot of minutiae will be presented to you during these early years, and the ideal student will learn it all. However, pragmatically, this is not possible for most of us. What is important to remember is that most of your examiners are clinicians first, so focus on what the clinically relevant questions will be. In fact, looking at USMLE Step 1 books and review guides can be very helpful, as these are the types of clinical vignettes people use to test basic science material. For example, in infectious diseases, knowing the structure of the bacterium is ultimately not as important as knowing how the disease presents and how you treat it. When push comes to shove, focus on clinical presentation, diagnosis, and treatment over the more 'basic science' aspects of the material.

When in doubt, ask - Simple advice, but sometimes, we are all averse to asking questions for fear of looking dumb or inconveniencing the professor. However, in this age of email, it never hurts to shoot off an email with well-phrased questions than you have already tried to answer. Whenever I did this, I usually received a thoughtful response. In retrospect, I wish I had done this more. This not only helps academically, but it helps to also develop relationships with people in fields you may be interested in in the future when you have to choose a specialty.

Enjoy what you are doing - If you find yourself getting bored while you study, stop. Take a break, and think of a way to make what you are studying interesting, whether that is by turning it into a game, making it interactive, more visual, or even reading interesting case reports online of a related disease. Sometimes, pegging the knowledge onto a case report or vignette can make the information much more "sticky" in your mind, which is all that matters. The New England Journal of Medicine has many such case reports, most excellently written, as do many other journals.

Best of luck in your first year! Developing good study habits now will not only serve you during the rest of medical school, but throughout your medical careers.

That being said, there is a broad discussion online about what constitutes a good stethoscope. For example, Half MD argues against the Littmann Cardiology III in favor of the Welch Allyn Tycos stethoscope:

I don’t like it. I haven’t been able to hear as well with it as the marketing propaganda would claim. The fans will instantly cry out, “But it has a tunable diaphragm.” To which I would respond, “Do you even know what a tunable diaphragm is? And furthermore, if you pay any attention to the research that was conducted on stethoscopes beginning over 50 years ago, you’d realize that a tunable diaphragm is the exact feature that a stethoscope should not have.”

I prefer the Welch Allyn Tycos DLX. The sound quality is much, much better compared to the Littman. It has interchangeable ear pieces that come in various varieties of stiffness so that the user can choose based on comfort level. Finally, the diaphragm can be easily changed to a pediatric version. All I have to do is unscrew the adult version and then replace it with a pediatric one to convert my stethoscope into a listening device for the kids.

Buying an expensive stethoscope because you don’t want to lose out is an absolutely ridiculous reason. Unless you’re buying a China-made $17 stethoscope, there’s almost no loss in skills of cardiovascular/respiratory/etc. examination with a $95 Littmann Classic II SE compared to the rest. Don’t let your friends pressure you into this.
That said, J. supports the 3M Littmann Classic SE, and not because it has tradition on its side. It is light, bendy (knots can be tied in it), of good quality, available in grey and most importantly, way cheaper than its more illustrious counterparts.
And of course, J. refuses to cave in to herd mentality: "everyone’s using at least a Cardiology III, mustn’t lose out!"

Ultimately, my view is that any of the Littmann or Welch-Allyn stethoscopes will provide decent enough sound quality and functionality to get through medical school. The two sets of students I would caution to think a little more deeply about their decision is anyone interested in cardiology or in pediatrics. For the cardiology people, investigate your decision a little more closely and try out several scopes to see which works best for you. Read reviews online and ask cardiology fellows and attendings for their advice. For the peds people, consider getting a pediatric sized stethoscope. I am not sure if it actually helps you hear heart sounds that much better than a regular adult stethoscope, but it makes sense given the patient population.

Confused yet? As I said before, the default gold standard seems to be the Littmann Cardiology III stethoscope so try that first. If you already have a stethoscope, what type do you have? Are you happy with how well it helps you during your cardiovascular and pulmonary exams?

Sunday, September 13, 2009

While I am sure your classes will provide you with curricula and suggested texts to read, there are several textbooks that any first year medical student should consider buying as part of their long-term collection of books. Looking back at some of my book purchases, it is shocking to see the books that I omitted and the ones I blew hundreds of dollars on only to have them collect dust.

What Books Should Every First Year Medical Student Own?

There is no definitive list of books, of course. But, I think the list below would serve any medical student well, since these topics are cornerstones of any medical education. Besides, we all have to take USMLE Step 1 at some point, right?

Every medical student will have to master anatomy regardless of what field they go into. I really liked how well-drawn and clear the Netter drawings and illustrations were. Even now, a few years later, any time I have a question about anatomy, it is the first text I turn to. Although I never used them for studying, I am aware that some find the Netter's Anatomy Flash Cards to be quite helpful as well.

I also found Color Atlas of Anatomy: A Photographic Study of the Human Body to be helpful. Seeing the anatomy in photograph form is much more similar to how you would see it on an anatomy practical, or actual patient. It helps to open up both Netter's and the photographic atlas to correlate the ideal anatomy to the actual stuff.

As I have mentioned before, Step 1 is a high-stakes test for any medical student. Obtaining First Aid early and reviewing it as you learn the material initially will just solidify the content for you two years down the road when you have that giant test to study for. In fact, if you annotate the book as you go along, you will create this wonderful resource for yourself that you are intimately familiar with when it comes time to crack open the books to study for the boards.

All the major techniques for history taking and physical exams are covered in this book. I like how the diagrams are clear and the sidebar notes highlight important points and diagnoses. The book is really indispensable when you are first learning basic exam technique and the significance of certain results. If you are interested, check out the pocket version as well: Bates' Pocket Guide to Physical Examination and History Taking, North American Edition

Infectious diseases is another cornerstone of any medical education. This book uses numerous techniques to help you learn about infectious agents, including many (bad) puns, funny diagrams, explanatory text, and tables grouping similar agents. It really is easy and even fun to read, which makes learning this otherwise seemingly disparate set of information not so bad. And yea, it's easy to review when Step 1 rolls around too.

The definitive book on general pathology. I thought the book did an excellent job not only describing the underlying pathology of almost any major disease you can imagine, but it often clearly explained the physiology as well. Definitely the best reference book I bought and the one I used most often, especially when very detailed questions came up during pathology and immunology.

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I still own all these books, used them throughout Step 1 (and Step 2) studying, and still refer to them as needed today. Do you know any other books that you think every pre-clinical medical student should have? Any books you disagree with in the list above? Leave a comment with your best book suggestions.

Sunday, September 06, 2009

Welcome Class of 2013! By now most of you are a few weeks into the medical school experience. Hopefully you have had time to settle into your new surroundings, make some new friends, and perhaps learn a thing or two.

You may have also noticed that medical school requires a different approach to studying. The way I look at it, to get into medical school, you had to be broadly talented, doing well in many subjects and perhaps especially well in one or two. The emphasis was more on being able to apply knowledge and problem solve (remember all those orgo and physics problem sets? Yea... ) However, the emphasis shifts drastically in medical school: it is simply an issue of rote memorization now. A person with photographic memory but no prior science background would likely be at the top of any medical school class, at least during the pre-clinical years. Another way to look at it is the information you are now expected to know is an oceanwide but only an inch deep.

How does one manage to internalize all this information in the short span of two years? I think the main thing (which I wish I had picked up on earlier) is learning from a clinical perspective and utilizing the advice of those that have gone before you heavily. Unlike prior educational experiences, there is much to be gained in medical school from talking to upperclassmen about specific courses and what is truly important down the road. For example, our infectious disease class spent a lot of time categorizing different viruses into single stranded or double stranded, positive or negative, and other features. However, these barely showed up on the test. And, from a clinical perspective this makes sense: the molecular features of the agents is only relevant to the virologists; the clinician could care less.

Thinking clinically is one of the keys to doing well in the pre-clinical years, especially if your test is being written by a clinician. The next few posts will serve to help first year medical students with various first year queries, such as which books are most helpful to first years, regardless of your med school or coursework. Good luck!

Tuesday, September 01, 2009

Along with the surgery rotation, the internal medicine rotation is arguably the most important rotation you will take during your clinical training in medical school. Of course, if you choose to specialize or go into another primary care field like pediatrics, those rotations will count a great deal. However, every student will be greatly benefited by doing well in medicine and surgery. The grade you receive on this rotation is on par with your surgery grade and second only to the USMLE Step 1 score in terms of factors that residency program directors evaluate. Your grade will likely be a mix of clinical evaluation and your shelf exam score. However, since the evaluations tend to average out to the same values, the shelf exam is what separates the great students from the good ones.

To do well on the rotation requires the usual medical student qualities of diligence and compassion, but the three main things to know are: know your patient, know your physiology, and know your pharmacology. If you know those three things and study hard, you will succeed. But, how does a medical student acquire all that knowledge in short period of time? The key is studying good resources efficiently. Here are my recommendations:

This review book covers major areas within medicine by organ system. It is well-organized and easy to read, with many tips and mnemonics detailed in the margins. I also found the flow charts helpful for thinking through certain conditions, such as what to do for a hypoxic patient.

If you are familiar with the Case Files series, then you know that these books are a good way to get up to speed on any clerkship. They are quick to read, but really help you understand the basic concepts and cases within a specialty. Read this book right before your rotation starts or during the first week. The book contains 60 cases of common diagnoses within internal medicine, specifically a patient vignette, followed by a description of the workup, background on the diagnosis, and review questions.

While on the wards themselves, you cannot refer to a full reference book for information. That's where Pocket Medicine comes in. The guide is a fairly comprehensive reference that fits in the pocket of your white coat. While it does not go into detail about pathophysiology of disease, it has a lot of information about clinical guidelines, relevant trials, and most importantly, how to manage common medical problems, from congestive heart failure to hyperkalemia to lower GI bleeding.

If you can master the content in these three books, you will do well on your internal medicine rotation. And, as always, remember to keep your differential broad and your therapeutic options broader.